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Ridha B, Hey N, Ritchie L, Toews R, Turcotte Z, Jamison B. Predicting the need for urgent endoscopic intervention in lower gastrointestinal bleeding: a retrospective review. BMC Emerg Med 2024; 24:71. [PMID: 38654175 DOI: 10.1186/s12873-024-00990-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/18/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common reason for emergency department visits and subsequent hospitalizations. Recent data suggests that low-risk patients may be safely evaluated as an outpatient. Recommendations for healthcare systems to identify low-risk patients who can be safely discharged with timely outpatient follow-up have yet to be established. The primary objective of this study was to determine the role of patient predictors for the patients with LGIB to receive urgent endoscopic intervention. METHODS A retrospective chart review was performed on 142 patients. Data was collected on patient demographics, clinical features, comorbidities, medications, hemodynamic parameters, laboratory values, and diagnostic imaging. Logistic regression analysis, independent samples t-testing, Mann Whitney U testing for non-parametric data, and univariate analysis of categorical variables by Chi square test was performed to determine relationships within the data. RESULTS On logistic regression analysis, A hemoglobin drop of > 20 g/L was the only variable that predicted endoscopic intervention (p = 0.030). Tachycardia, hypotension, or presence of anticoagulation were not significantly associated with endoscopic intervention (p > 0.05). CONCLUSIONS A hemoglobin drop of > 20 g/L was the only patient parameter that predicted the need for urgent endoscopic intervention in the emergency department.
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Affiliation(s)
- Barzany Ridha
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Royal University Hospital, 104 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
| | - Nigel Hey
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Royal University Hospital, 104 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada
| | - Lauren Ritchie
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Royal University Hospital, 104 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada
| | - Ryan Toews
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Royal University Hospital, 104 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada
| | - Zachary Turcotte
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Royal University Hospital, 104 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada
| | - Brad Jamison
- Department of Emergency Medicine, College of Medicine, University of Saskatchewan, Royal University Hospital, 104 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada
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Jiang M, Li CL, Lin XC, Xu LG. Early warning system enables accurate mortality risk prediction for acute gastrointestinal bleeding admitted to intensive care unit. Intern Emerg Med 2024; 19:511-521. [PMID: 37740869 DOI: 10.1007/s11739-023-03428-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/04/2023] [Indexed: 09/25/2023]
Abstract
Acute gastrointestinal (GI) bleeding are potentially life-threatening conditions. Early risk stratification is important for triaging patients to the appropriate level of medical care and intervention. Patients admitted to intensive care unit (ICU) has a high mortality, but risk tool is scarce for these patients. This study aimed to develop and validate a risk score to improve the prognostication of death at the time of patient admission to ICU. We developed and internally validated a nomogram for mortality in patients with acute GI bleeding from the eICU Collaborative Research Database (eICU-CRD), and externally validated it in patients from the Medical Information Mart for Intensive Care III database (MIMIC-III) and Wuhan Tongji Hospital. The performance of the model was assessed by examining discrimination (C-index), calibration (calibration curves) and usefulness (decision curves). 4750 patients were included in the development cohort, with 1184 patients in the internal validation cohort, 1406 patients in the MIMIC-III validation cohort, and 342 patients in the Tongji validation cohort. The nomogram, which incorporated ten variables, showed good calibration and discrimination in the training and validation cohorts, yielded C-index ranged from 0.832 (95%CI 0.811-0.853) to 0.926 (95CI% 0.905-0.947). The nomogram-defined high-risk group had a higher mortality than the low-risk group (44.8% vs. 3.5%, P < 0.001; 41.4% vs 3.1%, P < 0.001;53.6% vs 7.5%, P < 0.001; 38.2% vs 4.2%, P < 0.001). The model performed better than the conventional Glasgow-Blatchford score, AIMS65 and the newer Oakland and Sengupta scores for mortality prediction in both the derivation and validation cohorts concerning discrimination and usefulness. Our nomogram is a reliable prognostic tool that might be useful to identify high-risk acute GI bleeding patients admitted to ICU.
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Affiliation(s)
- Meng Jiang
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.
| | - Chang-Li Li
- Department of FSTC Clinic, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Xing-Chen Lin
- Emergency and Trauma Center, The First Affiliated Hospital, Zhejiang University School of Medicine, #79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China
| | - Li-Gang Xu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
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Lyhne CN, Bjerrum M, Riis AH, Jørgensen MJ. Interventions to Prevent Potentially Avoidable Hospitalizations: A Mixed Methods Systematic Review. Front Public Health 2022; 10:898359. [PMID: 35899150 PMCID: PMC9309492 DOI: 10.3389/fpubh.2022.898359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The demand for healthcare is increasing due to an aging population, more people living with chronic diseases and medical comorbidities. To manage this demand, political institutions call for action to reduce the potentially avoidable hospitalizations. Quantitative and qualitative aspects should be considered to understand how and why interventions work, and for whom. The aim of this mixed methods systematic review was to identify and synthesize evidence on interventions targeting avoidable hospitalizations from the perspectives of the citizens and the healthcare professionals to improve the preventive healthcare services. Methods and Results A mixed methods systematic review was conducted following the JBI methodology using a convergent integrated approach to synthesis. The review protocol was registered in PROSPERO, reg. no. CRD42020134652. A systematic search was undertaken in six databases. In total, 45 articles matched the eligibility criteria, and 25 of these (five qualitative studies and 20 quantitative studies) were found to be of acceptable methodological quality. From the 25 articles, 99 meaning units were extracted. The combined evidence revealed four categories, which were synthesized into two integrated findings: (1) Addressing individual needs through care continuity and coordination prevent avoidable hospitalizations and (2) Recognizing preventive care as an integrated part of the healthcare work to prevent avoidable hospitalizations. Conclusions The syntheses highlight the importance of addressing individual needs through continuous and coordinated care practices to prevent avoidable hospitalizations. Engaging healthcare professionals in preventive care work and considering implications for patient safety may be given higher priority. Healthcare administers and policy-makers could support the delivery of preventive care through targeted educational material aimed at healthcare professionals and simple web-based IT platforms for information-sharing across healthcare settings. The findings are an important resource in the development and implementation of interventions to prevent avoidable hospitalizations, and may serve to improve patient safety and quality in preventive healthcare services. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=134652, identifier: CRD42020134652.
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Affiliation(s)
- Cecilie Nørby Lyhne
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Research, Horsens Regional Hospital, Horsens, Denmark
- *Correspondence: Cecilie Nørby Lyhne
| | - Merete Bjerrum
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Centre for Clinical Guidelines and Danish Centre of Systematic Reviews, A JBI Centre of Excellence, Aalborg University, Aalborg, Denmark
| | - Anders Hammerich Riis
- Department of Research, Horsens Regional Hospital, Horsens, Denmark
- Enversion A/S, Aarhus, Denmark
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Morgan TG, Carlsson T, Loveday E, Collin N, Collin G, Mezes P, Pullyblank AM. Needle or knife? The role of interventional radiology in managing uncontrolled gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii200018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thomas G. Morgan
- Dpeartment of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Eric Loveday
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Neil Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Graham Collin
- Departments of Radiology, Southmead Hospital, Bristol, UK
| | - Peter Mezes
- Departments of Radiology, Southmead Hospital, Bristol, UK
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The impact of a multidisciplinary algorithmic approach to acute lower gastrointestinal bleeding. Am J Emerg Med 2019; 37:1751-1753. [DOI: 10.1016/j.ajem.2019.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/19/2022] Open
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Abstract
Lower gastrointestinal bleeding entails a range of severity and a multitude of options for localization and control of bleeding. With experience in trauma, critical care, endoscopy, and definitive surgical interventions, general surgeons are equipped to manage this condition in various clinical settings. This article examines traditional and emerging options for bleeding localization and control available to general surgeons.
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Mohammed Ilyas MI, Szilagy EJ. Management of Diverticular Bleeding: Evaluation, Stabilization, Intervention, and Recurrence of Bleeding and Indications for Resection after Control of Bleeding. Clin Colon Rectal Surg 2018; 31:243-250. [PMID: 29942215 DOI: 10.1055/s-0037-1607963] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Diverticular bleeding is the most common cause of lower gastrointestinal bleeding with nearly 200,000 admissions in the United States annually. Less than 5% of patients with diverticulosis present with diverticular bleeding and present usually as painless, intermittent, and large volume of lower gastrointestinal bleeding. Management algorithm for patients presenting with diverticular bleeding includes resuscitation followed by diagnostic evaluation. Colonoscopy is the recommended first-line investigation and helps in identifying the stigmata of recent hemorrhage and endoscopic management of the bleeding. Radionuclide scanning is the most sensitive but least accurate test due to low spatial resolution. Angiography is helpful when patients are actively bleeding and therapeutic interventions are performed with angioembolization. Surgery for diverticular bleeding is necessary when associated with hemodynamic instability and after failed endoscopic or angiographic interventions. When the bleeding site is localized preoperatively, partial colectomy is sufficient, but subtotal colectomy is necessary when localization is not possible preoperatively.
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Affiliation(s)
| | - Eric J Szilagy
- Department of Colon and Rectal Surgery, West Bloomfield Hospital, Henry Ford Health System, Detroit, Michigan
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More Is Not Always Better: A Randomized Trial Of Low Volume Oral Laxative, Enemas, And Combination Of Both Demonstrate That Enemas Alone Are Most Efficacious For Preparation For Flexible Sigmoidoscopy. Clin Transl Gastroenterol 2016; 7:e156. [PMID: 26986656 PMCID: PMC4822094 DOI: 10.1038/ctg.2016.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/16/2016] [Accepted: 01/21/2016] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Colon cleansing for flexible sigmoidoscopy using a standard fleet enema does not provide adequate cleansing in a significant number of patients. We tested whether the addition of a low-volume oral cleansing agent could mitigate this challenge without significantly compromising patient tolerance. HYPOTHESIS Oral picosulfate with magnesium citrate (P/MC) would enhance the colon cleansing of patients undergoing sigmoidoscopy, as assessed by the modified Ottawa Bowel Preparation Score. METHODS A randomized single blinded trial comparing (1) a single dose (i.e., one sachet) of oral sodium picosulfate plus magnesium citrate (P/MC) administered the night before, (2) a single dose oral P/MC the night before plus sodium phosphate enema 1 h before leaving home, and (3) sodium phosphate enema alone 1 h before leaving home for flexible sigmoidoscopy was conducted on outpatients referred for sigmoidoscopy for symptom assessment. RESULTS A total 120 patients were randomized to the study groups. The main indication for sigmoidoscopy was investigation of rectal bleeding (n=80). There was no significant difference in bowel cleansing quality, measured by the endoscopist blinded to preparation, between P/MC, P/MC plus enema, and enema alone as measured by the modified Ottawa Bowel Preparation Scale (P=0.34) or the Aronchick Scale (P=0.13). Both oral P/MC regimens were associated with higher incidence of nausea, abdominal pain, bloating, and interrupted sleep than enema alone (P<0.05). CONCLUSIONS A single dose of oral P/MC administered the night before did not result in better colon cleansing for sigmoidoscopy when used alone or with an enema and was associated with more side effects (NCT 01554111).
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Moss AJ, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis 2016; 31:175-88. [PMID: 26454431 DOI: 10.1007/s00384-015-2400-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition. METHODS Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients. FINDINGS The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention. CONCLUSIONS There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.
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Affiliation(s)
- Andrew J Moss
- Department of Surgery, Peterborough City Hospital, Peterborough, Cambridgeshire, PE3 9GZ, UK
| | - Hussein Tuffaha
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK.
| | - Arshad Malik
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK
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